Provider Demographics
NPI:1790712727
Name:DEGERSTROM, SEAN DARRELL (ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:DARRELL
Last Name:DEGERSTROM
Suffix:
Gender:M
Credentials:ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:TIFFIN
Mailing Address - State:OH
Mailing Address - Zip Code:44883-2831
Mailing Address - Country:US
Mailing Address - Phone:419-443-8164
Mailing Address - Fax:
Practice Address - Street 1:310 E MARKET ST
Practice Address - Street 2:
Practice Address - City:TIFFIN
Practice Address - State:OH
Practice Address - Zip Code:44883-2434
Practice Address - Country:US
Practice Address - Phone:419-448-2154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0022982255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer